Makindo Medical Notes

Related Subjects: | Nikolsky's sign | Koebner phenomenon | Erythema Multiforme | Pyoderma gangrenosum | Erythema Nodosum | Dermatitis Herpetiformis | Lichen Planus | Acanthosis Nigricans | Acne Rosacea | Acne Vulgaris | Alopecia | Vitiligo | Urticaria | Basal Cell Carcinoma | Malignant Melanoma | Squamous Cell Carcinoma | Mycosis Fungoides (Sezary Syndrome) | Xeroderma pigmentosum | Bullous Pemphigoid | Pemphigus Vulgaris | Seborrheic Dermatitis | Pityriasis/Tinea versicolor infections | Pityriasis rosea | Scabies | Dermatomyositis | Toxic Epidermal Necrolysis | Stevens-Johnson Syndrome | Atopic Eczema/Atopic Dermatitis | Psoriasis

Acne vulgaris commonly begins during early puberty, with increased activity throughout the teenage years. It often resolves spontaneously after the teen years.

About Acne Vulgaris

• Acne vulgaris is inflammation of the pilosebaceous unit of the skin.
• It primarily affects adolescents but may continue into adulthood, sometimes causing scarring.

Aetiology

• The cause is multifactorial, with a possible genetic component.
• More common in males during adolescence, but more prevalent in females during adulthood.
• It involves hormones, skin lipid composition, inflammation, and excessive sebum production.
• Acne is associated with an overgrowth of *Propionibacterium acnes* bacteria.
• Characterized by hyperproliferation of epithelial cells, leading to blocked ducts and follicular rupture.
• Histopathology shows distended pilosebaceous units infiltrated with neutrophils.

Old Myths

• Acne is caused by dirt or poor personal hygiene.
• It is linked to poor diet.

Causes/Exacerbating Factors

• Conditions like congenital adrenal hyperplasia and polycystic ovary syndrome (PCOS).
• Endocrine disorders such as Cushing's syndrome and high androgen levels.
• Medications including steroids, lithium, and some antiepileptic drugs.
• Any condition that causes excess androgen production can exacerbate acne.

Clinical Presentation

• The primary lesion is the microcomedo, which is clinically unrecognizable.
• Open comedones (blackheads) form without inflammation, while closed comedones (whiteheads) are caused by melanin oxidation.
• Progression can lead to papules, pustules, nodules, and cysts.
• Common sites include the face, neck, chest, back, and shoulders.
• Symptoms may worsen during menstruation due to hormonal fluctuations.

Acne Conglobata

Acne Conglobata is a rare but severe form of acne characterized by deep, inflamed nodules, abscesses, and interconnected sinuses that can lead to extensive scarring. It primarily affects the face, chest, back, and shoulders and is one of the most severe forms of nodulocystic acne.

Severity

• Mild: Characterized by open and closed comedones with or without sparse inflammatory lesions.
• Moderate: Widespread non-inflammatory lesions with many papules and pustules.
• Severe: Extensive inflammatory lesions, which may include nodules, pitting, and scarring.

Types of Acne Vulgaris Severity

• Type I: Comedonal acne with minimal inflammation and no scarring.
• Type II: Comedonal and papular, moderate lesions with little scarring.
• Type III: Comedonal, papular, and pustular acne with scarring.
• Type IV: Nodulocystic acne, which carries a high risk of severe scarring.

Investigations

• Investigations are rarely needed except in unusual or severe cases.
• Tests may include FSH, LH, Prolactin, SHBG, Testosterone, and 17(OH) progesterone levels.
• Abdominal CT is indicated if an adrenal tumour is suspected as a cause of androgen excess.

Differential Diagnoses

• Folliculitis.
• Acne Rosacea.
• Adenoma Sebaceum.

Management: See NICE Acne Vulgaris: Management (NG198)

• Skin care: Use non-alkaline (pH-neutral or slightly acidic) cleansers twice daily. Avoid oil-based products and ensure makeup is removed daily.
• Diet: Advise a balanced, healthy diet. No specific diet has proven effective for acne treatment.
• Acne Fulminans: Urgently refer to the hospital dermatology team for same-day assessment.

Referral to Specialists

• Diagnostic uncertainty or suspicion of acne conglobata or nodulocystic acne.
• Unresponsive mild to moderate acne after two completed courses of treatment.
• Moderate to severe acne unresponsive to prior treatments.
• Acne causing scarring or pigmentation changes.
• Acne with persistent psychological distress.
• Urgent referral for suicidal ideation, self-harm, or body dysmorphic disorder.

First-Line Treatments

• A 12-week course of one of the following treatments, adjusted for severity:
• Topical adapalene with topical benzoyl peroxide (avoid during pregnancy/breastfeeding).
• Topical tretinoin with topical clindamycin (avoid during pregnancy/breastfeeding).
• Benzoyl peroxide with clindamycin for mild to moderate cases.
• Adapalene with oral antibiotics for moderate to severe cases (avoid during pregnancy/breastfeeding).

Note: Topical retinoids and oral tetracyclines are contraindicated during pregnancy and when planning pregnancy.

Review at 3 Months

• Assess acne improvement and any side effects. If on oral antibiotics, consider stopping them and continuing with topical treatments if acne is cleared.
• If acne has improved but not fully cleared, continue oral antibiotics alongside topical treatment for up to 12 more weeks.

Oral Isotretinoin Treatment

• Consider oral isotretinoin for people over 12 years old with severe acne unresponsive to standard therapy.
• For individuals under 18, ensure agreement from two independent healthcare professionals before prescribing.
• Discuss psychological wellbeing before starting treatment.
• For individuals at risk of pregnancy, explain the risks of isotretinoin during pregnancy and follow the MHRA pregnancy prevention program.

Steroid Management

• If an acne flare occurs after starting isotretinoin, consider adding oral prednisolone.
• Treat severe cysts with intralesional triamcinolone acetonide injections.

Images and Guidelines

• NICE Guideline: Acne Vulgaris Management (NG198)